Emergency Management:

Traumatic Brain Injury

Woothichai Madjupa, MD
Buriram Hospital

Severity
Traumatic brain injury

Cause of death

3
2

Buriram hospital:
Mortality report 2014

What is the most important?:

TBI management

 To

be a neurosurgeon in 1 hour

Objective

 In

hospital management

Referring

system

Prehospital

management

Emergency management in TBI:

How to?

What is the most important?:

TBI management

 Preventable

death and disability

GOAL

 Secondary

ischemic insults

Secondary

injury processes

Primary

injury

DEATH & DISABILITY; CAUSES

 O2

Consumption

O2

Delivery

SECONDARY ISCHEMIC INSULTS

Vasospasm
Hypocarbia
Hypotension
Increased

ICP

Anemia
Hypoxia

DECREASED O2 DELIVERY

 Hyperglycemia
Seizures
Fever

INCREASED O2 CONSUMPTION

 Traumatic
Cerebral

brain swelling

ischemia

SECONDARY INJURY PROCESSES

 Hematoma
Diffuse

and contusion

axonal injury

PRIMARY INJURY

 Non-preventable
Preventable

DEATH & DISABILITY; CAUSES

 Secondary

ischemic insults

Secondary

injury processes

PREVENTABLE CAUSES

 Normovolemia
Isotonic

crystalloid; NSS

PREVENT:
Traumatic brain swelling

 Cerebral

blood flow adequacy

Cerebral

perfusion

PREVENT:
Cerebral ischemia

 PaO2

> 80 mmHg

Monitor

O2 saturation > 95%

Adequate

oxygenation

PREVENT:
Hypoxia

 Stop

external bleeding

PREVENT:
Anemia

 Normovolemia
Isotonic
Stop

crystalloid; NSS

external bleeding

PREVENT:
Hypotension

Avoiding

constipation

Avoiding

internal or external jugular vein compression

Neutral
Head
ICP

head & neck position

elevation

monitoring

Adequate

sedation before intubation

PREVENT:
Intracranial hypertension

 PaCO2

35-40 mmHg

Control

ventilation

Normoventilation

PREVENT:
Hypocarbia

 TCD

ultrasound monitoring

Occur

in Days 5-14

Associated

with SAH

PREVENT:
Vasospasm

 Control
Prevent

infection
dehydration

PREVENT:
Fever

 Indication;

immediate seizure, injury to cerebral

cortex or subcortex, or GCS 10

Early

seizure prophylaxis; anticonvulsant 7 days

post-trauma

PREVENT:
Seizures

 Dextrose
Normal

solution ?

saline solution ?

PREVENT:
Hyperglycemia

 Surgical

management

Nonsurgical

management

TREATMENT:
Intracranial hypertension

Barbiturate

coma

Hyperventilation
Mannitol
Neuromuscular
Sedation
Head

blocking agents

& Analgesia

elevation

Nonsurgical management:
Intracranial hypertension

 Decompressive
CSF

craniectomy

drainage

Surgical management:
Intracranial hypertension

IVH

ICH

SAH

SDH

EDH

Depressed skull fracture

Diffuse axonal injury

Cerebral concussion

TREATMENT:
Primary injury

 Dural

penetration, depression > 1 cm, frontal

sinus involvement, gross cosmetic deformity, w
ound infection, pneumocephalus or gross wound
contamination

Compound

depressed fracture
> thickness of skull

SURGICAL MANAGEMENT:
Depressed skull fracture

 Focal

deficit

Asymmetric

or fixed and dilated pupils

>

5 mm midline shift

>

15 mm thickness

SURGICAL MANAGEMENT:
EDH

 Asymmetric

or fixed and dilated pupils

>

5 mm midline shift

>

10 mm thickness

SURGICAL MANAGEMENT:
SDH

 Signs

of mass effect

Cisternal

compression

>

5 mm midline shift

>

30 cc

SURGICAL MANAGEMENT:
ICH

 Obstructive

hydrocephalus

SURGICAL MANAGEMENT:
IVH

Conclusion:
TBI management

NS
Primary Injury

ER: EP + Intern + Extern + Nurse

Ward: ICU:
Secondary Injury
Processes

Traumatic Brain Edema

Cerebral Ischemia

Secondary Ischemic
Insults
Hypoxia
Anemia
Increased ICP
Hypotension
Hypocarbia
Vasospasm
Seizures
Fever
Hyperglycemia

NS
Primary Injury

ER: EP + Intern + Extern + Nurse

Surgical
Management

General
Management

Special
Consideration

NS

ER: EP + Intern + Extern + Nurse

Ward: ICU:
Secondary Injury
Processes

Barbiturate
coma

Traumatic Brain Edema:

Intracranial
Hypertension

Hyperventilation
Isotonic
crystalloid:
NSS
Normovolemia:
Holliday-Segar

Mannitol
Neuromucular
blocking agents
Sedation &
Analgesia
Head elevation

O2 supplement
Stop bleeding
Isotonic
crystalloid: NSS
Normoventilation
Antiseizure
prophylaxis
Control infection

Cause of death
Referring system
Equipment failure
Infection
Diagnostic/ Judgement
problem
Secondary injury
Primary injury

Buriram hospital:
Mortality report 2014

Questions?

Thank you